Management of End-Stage Renal Disease in the Older Adult: Recent Advances and Future Challenges

Introduction

End-stage renal disease (ESRD), defined as chronic renal impairment severe enough to require renal replacement therapy, is rising in prevalence worldwide, and there are currently more than 500,000 patients with ESRD in the United States.¹ This number is projected to exceed 780,000 by 2020, with patients age 65 years and older representing the fastest growing component of the ESRD population.¹ As such, geriatricians and other healthcare providers must be familiar with common medical issues related to the older adult with ESRD. In a previous review, we discussed management issues in older adults with chronic kidney disease (CKD; Clinical Geriatrics, December 2008). In this article, we will highlight areas of concern associated with the management of older patients on dialysis, with particular focus on recent research that has advanced overall care of this population.

Incidence, Prevalence, and Survival

In the United States, there are currently more than 175,000 dialysis patients age 65 years or older, and this population continues to grow at an alarming rate. In fact, the median age of patients starting dialysis is now 64.4 years.¹ In patients age 75 years and older, the population incidence of ESRD is 1744 per million as compared to 127 per million in the 20-44 years age group, which represents a 65% increase during the past decade.¹ Similar trends have been observed in developed nations worldwide.^2-4

Many factors have contributed to the rising incidence of ESRD in the geriatric population, including an increased incidence of predisposing factors such as diabetes mellitus and CKD.⁵ Diabetes remains the leading cause of ESRD in the United States, accounting for nearly 50% of incident ESRD patients.¹ Other factors include improved survival from cardiovascular and cerebrovascular disease, the more widespread availability of dialysis, earlier initiation of dialysis, and lower thresholds for accepting patients into dialysis programs.^6,7

As seen with all age groups of ESRD, survival of older patients with ESRD is markedly diminished as compared to the age-matched general population (Figure). For example, U.S. adults age 65-69 years have a life expectancy of 17.2 years; the same age group of patients with ESRD has a life expectancy of only 3.9 years.¹ Kurella and colleagues⁷ recently evaluated the clinical course and outcomes of incident ESRD patients age 80 and older. In this cohort, survival at 1 year after dialysis initiation was only 54% and did not change significantly between 1996 and 2003.⁷ In contrast, a recent analysis of the Canadian Organ Replacement Registry suggested a trend toward improved survival among older adults with ESRD. Focusing on incident ESRD patients age 65 and older, Jassal et al8 noted a 15-20% increase in life expectancy during the period 1995-1999 as compared to 1990-1994. In Jassal’s study, 1-year survival among incident ESRD patients age 75 or older was 69%.⁸ The reason for the different findings between the studies is uncertain but may reflect practice differences between the United States and Canada, particularly with regard to patient selection for dialysis.

Renal Replacement Therapy Options

The three main treatment options for ESRD are hemodialysis, peritoneal dialysis (PD), and renal transplantation. In the geriatric population, hemodialysis has traditionally been considered the most viable option. However, recent studies suggest that increased consideration should be given to the other treatment modalities in older patients.

The overall use of PD continues to decline in the United States, and only 6.2% of all incident ESRD patients now choose this modality.¹ Choice of PD also declines with age: in 2006, 8.8% of incident ESRD patients age 45-64 chose PD as compared to 5.2% of patients age 65-74 and only 3.4% of patients 75 years and older.¹ Numerous reasons contribute to this trend, including later referral for pre-ESRD nephrology care, increasing incidence of medical contraindications to PD with age, and physician perception that older patients will not be able to perform self-dialysis at home.⁹ Yet PD may hold clinical advantages over hemodialysis in the older adult, such as improved hemodynamic stability and fewer adverse effects on cognition,¹⁰ and PD therapy is less costly than hemodialysis.^1,11 Recent studies have demonstrated comparable PD technique survival^12,13 and peritonitis risk,^14,15 regardless of patient age. As a result, many authors have advocated for the increased use of this modality in the older population.^13,16,17

Similar to PD, older age has been considered a relative contraindication for renal transplantation, due both to increased risk of complications and the shortage of donor organs. Currently, patients with ESRD who are age 65 and older comprise nearly 35% of the prevalent dialysis population but account for only 17% of the greater than 79,000 waitlisted patients in the United States.^1,18 However, transplantation rates in this age group have risen significantly over the past two decades,¹ and recent studies have suggested equivalent outcomes when comparing older (≥ 60 yr) to younger transplant recipients.^19,20 One recent advance in the transplant program with particular ramifications for older patients with ESRD has been the introduction of the expanded criteria donor (ECD) kidney waitlist (Table I). Previously, use of “marginal” organs was at the discretion of individual transplant centers and often led to discarding of potentially useable organs. With a more formal allocation program, ECD kidneys now account for approximately 20% of all adult kidney transplants.¹ Although ECD kidneys are, by definition, associated with a lower graft survival rate as compared to standard criteria donor (SCD) kidneys, transplantation with an ECD kidney in older patients with ESRD provides a significant survival advantage over continuing on maintenance dialysis.^21,22 Older adult patients with ESRD should therefore be encouraged to explore ECD listing as a means to lowering waitlist time and increasing access to transplantation.

Even with greater use of PD and transplantation, the vast majority of older adult patients with ESRD will continue to be managed by hemodialysis. This modality has the advantages of requiring minimal patient effort and maximizing exposure to a multidisciplinary team (including social workers and dieticians) that can respond promptly to medical and social needs. In-center hemodialysis also provides an opportunity for social interaction that may be particularly important in older patients at risk for social isolation. Nevertheless, complications of hemodialysis care are relatively common in the older ESRD population. High-risk areas include vascular access difficulties and functional decline; these are further discussed below.

Vascular Access Needs

Long-term hemodialysis requires a specialized dual-channel vascular access that can support blood flow rates upwards of 400 mL per minute. Options include a surgically created native vein arteriovenous fistula, a surgically created arteriovenous graft of synthetic material, or a cuffed, tunneled central venous catheter. Among these options, native vein fistulae are the preferred choice, as they are associated with lower mortality, have the lowest rates of infection, and require the fewest interventions.¹ Unfortunately, there is an inverse relationship between native vein fistula use and age. While patients in the age 20-44–year age group have a native vein fistula prevalence of over 50%, this rate falls to 42% and 40%, respectively, for the 65-74–year and the over-75–year age groups.¹

There are multiple reasons for the lower prevalence of native vein fistula use observed in older patients on dialysis, most notably an increased prevalence of atherosclerotic vascular disease. In patients with peripheral vascular disease, native vein fistula creation is often associated with prolonged fistula maturation times (time from surgical creation until the fistula is able to be used for dialysis) and increased incidence of primary fistula failure.²³ Conversely, synthetic grafts have the advantages of faster time-to-use and lower incidence of primary failure. Therefore, to avoid the risks inherent in catheter-associated hemodialysis, many have argued that synthetic grafts may be the superior option in this population. This was supported by a recent retrospective analysis of United States Renal Data System (USRDS) data, in which Chan and colleagues²⁴ concluded that the benefits of native vein fistulae over synthetic grafts might not extend to the over-65 population.

While peripheral vascular disease will likely remain a major obstacle to vascular access, there are several potentially modifiable factors that contribute to the low rate of native vein fistula use in older patients undergoing hemodialysis. First, patients and referring physicians often express concerns about the potential morbidity associated with surgery and may choose the “safer” option of percutaneous catheter placement. This is particularly relevant to the older population with comorbidities, in whom elective general anesthesia may be considered a contraindication. In reality, vascular access surgery is usually minimally invasive, and most often can be performed on an outpatient basis using regional anesthesia. Second, given that many older patients have significant cardiovascular comorbidity, there is a theoretical concern for high-output heart failure due to the increased cardiac venous return generated by creation of an arteriovenous fistula. In fact, several cohort studies, including one that focused specifically on the elderly, have shown that patients with native vein fistulae have a lower incidence of heart failure, acute coronary syndromes, and cardiovascular death as compared to those with central venous catheters.^25,26

Another aspect of improving vascular access outcomes is the preservation of healthy peripheral veins in patients at high risk of developing ESRD, an endeavor in which primary care physicians can play a major role. The National Kidney Foundation²⁷ and American Society of Diagnostic and Interventional Nephrology²⁸ have published similar vein preservation guidelines. Targeting patients with CKD stage 3 or later (estimated glomerular filtration rate < 60 mL/min), these recommendations include avoiding use of peripherally inserted central catheters and avoiding catheterization of subclavian veins. Both procedures are associated with high rates of central venous stenosis or thrombosis,^29-31 which may exclude the ipsilateral upper extremity as a site of future vascular access. Internal jugular veins are the preferred site for central venous access when necessary. In our practice, we also emphasize limiting venipunctures and blood pressure measurements in the nondominant upper extremities of patients with CKD.

Functional Considerations

Functional impairment is a well-established risk factor for poor clinical outcomes (including mortality) in the general population and is of particular concern in the geriatric population.³² Furthermore, focused interventional programs have been shown to prevent functional decline in the geriatric population.³³ Most of the early research in this area excluded patients with ESRD, but recent studies have shed light on the epidemiology and risk factors for functional decline in this vulnerable group.

Cook and Jassal³⁴ recently highlighted the high prevalence of disability in patients with ESRD age 65 or older. Using a definition of disability as dependency or difficulty with activities of daily living (ADL), they found that only 8 of 162 (4.9%) patients had no disability at all, while 52% of patients required assistance with at least one basic ADL (ie, ambulating ≥ 50 yards, bathing, dressing, or transferring from bed to chair).³⁴ These results emphasize the importance of functional screening in older patients with ESRD. But once identified, can functional decline in older patients with ESRD be reversed? A recent report by Li et al³⁵ provides an optimistic answer to this question. Using an inpatient ESRD-specific geriatric rehabilitation program, the investigators were able to restore independent function in a majority of patients, allowing 69% of patients to be discharged to a home setting.³⁵ Unfortunately, such intensive ESRD-dedicated programs are not widely available in the United States, where reimbursement issues may limit their economic feasibility. Whether standard rehabilitation programs provide equivalent outcomes has not been formally evaluated. Still, clinicians should routinely consider physical and occupational therapy referrals for older patients with ESRD.

Accidental falls represent a major contribution to morbidity and functional decline in older patients with ESRD. Fall risk appears to be higher in patients with ESRD as compared to the general population, with a recent study reporting that 47% of patients with ESRD age 65 years and older experienced a fall during a 2-year period.³⁶ Similar to the general geriatric population, occurrence of a fall is an independent predictor of subsequent mortality in patients with ESRD.³⁷ Risk factors for falls in patients with ESRD include older age, more comorbid conditions, higher number of prescription medications, impaired mobility, and a previous history of falls.^36,38 A dialysis-specific concern is the relatively common development of hypotension or orthostasis with fluid removal. Dialysis patients may also be at higher risk of fall-related fractures due to ESRD-related metabolic bone disease. Since falls are a potentially preventable complication, many dialysis centers have adopted screening protocols to try and identify high-risk patients. However, there are currently no published ESRD-specific guidelines for fall prevention. Future studies are needed to assess interventions in this very high-risk population.

Palliative Care and Withdrawal from Dialysis

In 2000, the Renal Physicians Association and American Society of Nephrology published clinical practice guidelines regarding withholding or withdrawal from dialysis in patients with ESRD or acute renal failure, thus formally asserting these as acceptable treatment options.³⁹ Today, withdrawal from dialysis accounts for nearly 25% of all deaths in patients with ESRD in the United States, and this proportion has increased during the past decade.¹ The incidence of dialysis withdrawal also increases with older age.1 For most outpatients, the primary reason for dialysis discontinuation is failure to thrive, while hospitalized patients choose this option mainly due to comorbid medical complications.¹

Despite the overall high mortality and high rate of dialysis withdrawal, only 19% of patients with ESRD utilize hospice services.¹ One barrier has been confusion over hospice eligibility. Because of Medicare coverage regulations, patients with ESRD who wish to continue dialysis are usually not accepted into hospice programs, as those programs would become financially responsible for the dialysis care. However, patients who have a terminal diagnosis other than ESRD (eg, cancer, advanced heart failure) can be enrolled in hospice while continuing on dialysis and receiving Medicare coverage for both services.⁴⁰ Certainly, all patients planning withdrawal from dialysis should have a hospice consultation, ideally prior to actual dialysis cessation.

An essential component to improving palliative care in ESRD is the proper education and counseling of patients and their families. In our experience, patients are often not even aware that withdrawal is an option. Many patients and family members tend to emphasize quantity of life, and discussions focusing on quality of life may help shape decision making. Sometimes it is these discussions that uncover potentially treatable conditions, such as chronic pain or depression. As patients move toward a decision to stop dialysis, members of the healthcare team must be able to provide a realistic picture of what to expect, and recent research has helped shed some light on this area. Here, we present a sample of the questions that are most frequently encountered when discussing withdrawal from dialysis with patients:

How long will I live after stopping dialysis?
The median survival is 8 days, and greater than 95% of patients die within 30 days.⁴¹ However, survival may vary greatly based on a patient’s residual renal function and other comorbidities.

What kinds of symptoms can be expected? Is dying from kidney failure painful?
Uremia has traditionally been viewed as a peaceful way to die, but recent studies have demonstrated a high prevalence of symptoms, including chronic pain in 50% of patients.^42,43 Other symptoms include pruritus, nausea, agitation, myotonic jerks, and dyspnea. Proper awareness allows for planning and anticipatory management, and symptomatic relief is achievable in nearly all patients. Hospice programs are ideally suited to optimize comfort during this period.

Is stopping dialysis considered a form of suicide?
From a medical perspective, the decision to stop dialysis is not considered suicide, but rather a patient right under the ethical principle of autonomy; legally, this choice is supported under a patient’s right to self-determination.^40,44 Similarly, most theologians do not consider withdrawal from dialysis to be suicide,⁴⁵ although patients should be encouraged to consult with their religious advisors as part of the decision-making process.

Can I change my mind and return to dialysis?
Yes, the decision to withdraw is reversible, and most dialysis centers will continue to maintain at least an informal relationship with patients who choose to withdraw from dialysis.

Table II provides additional resources specific to palliative care for ESRD.

Summary

The incidence and prevalence of ESRD continue to rise, particularly in the geriatric population. In recognition of this, there is growing interest in this population, and recent research has refined our perspectives of ESRD care in the older adult. Studies support increasing access to both PD and transplantation in older patients with ESRD. In particular, use of ECD kidneys can increase access to transplantation (and, therefore, improved survival). Practitioners should be aware of the very high prevalence of functional impairment and decline in the geriatric ESRD population and the subsequent contribution to mortality. Withdrawal from dialysis is an increasingly chosen option, and healthcare providers need to gain expertise in counseling patients regarding this decision. Despite recent progress, there remains a great deal of uncertainty about best practices in caring for older adults with ESRD, and additional prospective evaluations are needed.

The authors report no relevant financial relationships.

Drs. Heung and Leavitt are from the Division of Nephrology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor; and Dr. Malani is from the Division of Infectious Diseases and the Division of Geriatric Medicine, Department of Internal Medicine, University of Michigan Health System, and the Veterans Affairs Ann Arbor Healthcare System and Geriatric Research, Education and Clinical Center (GRECC).